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School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
Physical Therapy Center, National Taiwan University Hospital, Taipei, Taiwan
Background: Knowledge of the kinematics and associated muscular activity in individuals with scapular
dyskinesis may provide insight into the injury mechanism and inform the planning of treatment strategies.
We investigated scapular kinematics and associated muscular activation during arm movements in individuals with scapular dyskinesis.
Methods: A visual-based palpation method was used to evaluate 82 participants with unilateral shoulder
pain. Scapular movements during arm raising/lowering movements were classified as abnormal single
pattern (inferior angle prominence, pattern I; medial border prominence, pattern II; excessive/inadequate
scapular elevation or upward rotation, pattern III), abnormal mixed patterns, or normal pattern (pattern
IV). Scapular kinematics and associated muscular activation were assessed with an electromagnetic
motion-capturing system and surface electromyography.
Results: More scapular internal rotation was found in pattern II subjects (4 , P .009) and mixed pattern I
and II subjects (4 , P .023) than in control subjects during arm lowering. Scapular posterior tipping (3 ,
P .028) was less in pattern I subjects during arm lowering. Higher upper trapezius activity (14%, P .01)
was found in pattern II subjects during arm lowering. In addition, lower trapezius (5%, P .025) and serratus anterior activity (10%, P .004) were less in mixed pattern I and II subjects during arm lowering.
Conclusions: Specific alterations of scapular muscular activation and kinematics were found in different
patterns of scapular dyskinesis. The findings also validated the use of a comprehensive classification test to
assess scapular dyskinesis, especially in the lowering phase of arm elevation.
Level of evidence: Basic Science Study, Kinesiology.
2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Scapula; dyskinesis; kinematics; electromyography; clinical assessment; movement patterns
1058-2746/$ - see front matter 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.12.022
2
Although scapular dyskinesis is not directly related to
shoulder disorders, it has been reported in 68% to 100% of
individuals with shoulder disorders, including glenohumeral instability, rotator cuff disorders, and labral
tears.2,32,41 Dyskinesis is observed in patients with various
shoulder disorders that are related to changes in glenohumeral strain, subacromial space dimension, shoulder
muscle activation, and muscle strength.36,38,42
Evidence suggests that individuals with shoulder disorders present scapular kinematic abnormalities such as
decreased scapular upward rotation, decreased scapular
posterior tipping, and external rotation.23,27,39 Researchers
have also proposed that abnormal scapular motion may be
linked to weakness of periscapular muscles.6,7 Specifically,
excessive activation of the upper trapezius with inhibited
activation of the lower trapezius and serratus anterior has
been proposed to be related to altered scapular kinematics.
Given that shoulder disorders and scapular movement patterns are related, identifying the specific characteristics of
the different scapular movement patterns to help guide
treatment strategies may be important.
The clinical evaluation of scapular motion is challenging
because of the 3-dimensional (3-D) movement and the soft
tissues surrounding the scapula, which prevent direct measurement of scapular motion. Despite these difficulties,
methods of identifying scapular dyskinesis have been
described in previous studies, including visual observation,
linear measurement, and manual correction maneuvers.21,26,30,35,40 Visually based dynamic assessments classify dyskinesis by the degree of dyskinesis, presence or not
of dyskinesis, or pattern.21,26,40 For the degree of dyskinesis,
scapular motion during bilateral weighted shoulder elevation
is observed, and the dyskinesis is classified as normal, subtle,
or obvious.26 Uhl et al40 classified scapular motion as having
dyskinesis or not with a simple yes or no. Kibler et al21
classified scapular dyskinesis into 4 movement patterns:
inferior medial scapular border, medial border of scapula,
superior scapular border, and symmetric pattern.
The types of scapular dyskinesis are the focus of this
report. The purpose of this study was to investigate scapular
kinematics and associated muscular activation during arm
raising/lowering movements in individuals with scapular
dyskinesis. We hypothesized that each type of scapular
dyskinesis would have unique scapular kinematics and
associated muscle activation during arm movements.
Figure 1 Scapular dyskinesis patterns with specific alteration of scapular kinematics: pattern I (inferior angle of scapular prominence),
pattern II (medial border of scapular prominence), pattern III (excessive/inadequate scapular upward rotation or elevation), combination of
above patterns, and pattern IV (normal scapular movement).
in the raising and the lowering phases, modified by Kiblers
method.21 The 4 single patterns were inferior angle of the scapula
prominence (pattern I), medial border of the scapula prominence
(pattern II), abnormal scapular upward rotation/elevation (pattern
III), and normal movements (pattern IV; Fig. 1). The mixed patterns were combinations of at least 2 single patterns. We tested the
inter-rater reliability of this comprehensive classification test. The
k coefficients of the raising phase reached the moderate level
(k 0.49), and those in the lowering phase reached the moderate
to substantial level (k/kw 0.57/0.64).15
Procedures
Potential participants were recruited from an outpatient clinic in a
university hospital and through local Internet media. All eligible
volunteers gave written and informed consent before participation.
Men were asked to remove their shirts, and women were asked
to wear haltertops. Subjects were instructed to practice arm
elevation in the scapular plane and become familiar with the
tempo of a metronome. The starting position was arms at the side
of the body, elbow straight, and shoulder in neutral position.
Participants were asked to elevate the arms, using the thumb-up
position, to the end range over a 3-second count and then to lower
them over a 3-second count. The dumbbells in each hand weighed
2.3 kg (5 lb) or 1.4 kg (3 lb), depending on each subjects ability to
elevate the arm with visual analog score of <3. After 1 minute of
rest, participants performed 6 trials of bilateral, active, weighted
arm elevation in the scapular plane, and a therapist classified the
scapular motion into specific patterns of scapula dyskinesis.
After the evaluation of scapular dyskinesis, the kinematics
and sEMG data were collected during 5 trials of the same arm
Data reduction
Raw kinematic data were low-pass filtered at a 6-Hz cutoff frequency and converted into anatomically defined rotations. We
generally followed the International Society of Biomechanics
guidelines for constructing a shoulder joint coordinate system.43
The absolute axes defined by the FASTRAK device sensors
were converted to anatomically defined axes. Scapular orientation
relative to the thorax was described using a Euler angle sequence
of rotation about Zs (protraction/retraction), rotation about Ys
(downward/upward rotation), and rotation about X00 s (posterior/
anterior tipping). Scapular elevation was defined as the vertical
displacement of the scapular sensor during arm elevation. Humeral orientation relative to the scapula was described using a
4
Euler angle sequence in which the first rotation represented the
plane of elevation, the second rotation defined the amount of
elevation, and the third rotation described the amount of axial
rotation. Full bandwidth sEMG data, captured by data AcqKnowledge acquisition software (BIOPAC Systems Inc), were
reduced using a root mean square algorithm to produce sEMG
envelopes with an effective sampling rate of 50 samples per second and normalized to the MVIC. The EMG data for each muscle
were averaged for each phase of the middle 3 trials. A phase was
defined by a trigger marked and synchronized on sEMG data and
scapular kinematics data. The mean sEMG amplitude of each
phase is reported as a percentage of the MVIC.
To quantitatively characterize the scapular kinematics and
muscular activities, the kinematic data at 30 , 60 , 90 , and 120
and EMG data for the ranges of 0 to 30 , 30 to 60 , 60 to 90 ,
90 to 120 , and >120 in the raising and lowering phases of arm
movement in the scapular plane were used as dependent variables.
The mean of multiple trials from outcomes was used for data
analysis. According to previous research, a sample size of 15
participants each group was needed to detect differences of upward rotation angle (9 ) between dyskinesis and normal groups.37
Because great variety exists in the patterns in clinical conditions,
we primarily focused on comparisons of participants with inferior
angle or medial border of scapular prominence, which are the
most common dyskinesis patterns seen during the lowering phase
of arm elevation. As a result, we stopped the recruitment when 15
volunteers with inferior angle or medial border of scapular
prominence were first reached.
Statistical analyses
SPSS 17.0 software (IBM Inc, Armonk, NY, USA) was used for
data analysis. The Shapiro-Wilk test was performed to confirm
normal distribution of the kinematics and EMG data. If the result
showed non-normal distribution, then nonparametric analysis was
used. For data with normal distribution, two-way analysis of
variance with factors of group and angle was used to determine the
differences in kinematic data at 30 , 60 , 90 , and 120 and those
in EMG data for the ranges of 0 to 30 , 30 to 60 , 60 to 90 ,
90 to 120 , and >120 during the arm raising and lowering
phases between volunteers with specific scapular dyskinesis patterns and the normal pattern. Bonferroni corrections were used to
adjust for multiple pair-wise comparisons using significant a
levels as low to 0.0125 for kinematics data and 0.01 for EMG data.
For nonparametric data, the Mann-Whitney U test was used in
each angle during the arm raising and lowering phases to compare
participants with specific scapular dyskinesis patterns and the
normal pattern. If no significant difference was revealed, a clinical
difference with an effect size of 0.5 was reported.
Results
Figure 2 shows the flow chart of volunteer recruitment and
scapular dyskinesis pattern. Eighty-two subjects were
classified into different types of scapular dyskinesis. For the
raising phase, scapular dyskinesis was identified in 52
volunteers with normal scapular movement (pattern IV), 24
with excessive/inadequate scapular upward rotation or
elevation (pattern III), and so on. For the lowering phase,
Figure 2 Flow chart of study participants. EMG, electromyogram; MVIC, maximal voluntary isometric contraction.
Raising phase
Male sex
Age, y
Height, cm
Weight, kg
Duration of symptoms, mo
Dominant side, right
Involved side, right
Lowering phase
Male sex
Age, y
Height, cm
Weight, kg
Duration of symptoms, mo
Domiant side, right
Involved side, right
Pattern IV (n 52)
(Mean SD)
(Mean SD)
18
22.2
172.6
63.8
26.5
23
21
40
23.0
172.3
66.2
24.6
48
44
2.7
8.8
8.9
35.7
3.5
8.0
11.6
34.8
Pattern I (n 12)
Pattern II (n 24)
Pattern I II (n 21)
Pattern IV (n 15)
(Mean SD)
(Mean SD)
(Mean SD)
(Mean SD)
8
22.2 2.3
169.0 10.8
60.2) 6.9
16.5 16.8
11
11
21
23.0
172.5
66.9
17.6
21
17
15
22.2
171.8
62.9
30.4
21
20
12
23.5
175.3
69.6
34.2
14
11
2.2
7.3
12.6
17.4
2.1
8.1
9.1
46.2
5.0
7.6
8.9
36.4
Table II
Variable
Posterior tipping
Pattern I
Pattern IV
Internal rotation
Pattern II
Pattern I II
Pattern IV
120
90
60
30
(Mean SD)
(Mean SD)
(Mean SD)
(Mean SD)
5. 8)
10 5
4. 6)
84
4 12)
5 10)
1 8
2 7)
5 7)
3 5
3 4)
64
1 2)
32
2 6)
1 5)
3 4
1 5)
1 4)
2 4
normal group. Significantly decreased lower trapezius activity was found in patients with pattern I II dyskinesis
(5%) during arm lowering (P .025). In addition, serratus
anterior activity was significantly lower in patients with
pattern I II dyskinesis (10%) than in the normal group
during arm lowering (P .004). EMG data during the
lowering phase with clinical differences having an effect
size of at least 0.5 are presented in Table III. More upper
trapezius activation was also found in patients with pattern
I II dyskinesis group (effect size, 0.67-0.94), and less
serratus anterior activity was found in the pattern I dyskinesis (effect size. 0.56-0.81) and pattern II dyskinesis
groups (effect size, 0.50-1.10) than in the normal group.
Discussion
Scapular kinematics and associated muscle activation patterns are thought to influence various shoulder conditions
and outcomes such as pain, restricted range of motion, and
functional disability. On the basis of these propositions,
previous studies have identified inadequate posterior
tipping, external rotation, and upward rotation, and
decreased serratus anterior and lower trapezius/increased
upper trapezius muscle activities in individuals with
shoulder impingement.3,23,39 Understanding the scapular
kinematics and associated muscle activity corresponding to
specific types of scapular dyskinesis is of value if the
Variable
Upper trapezius (% MVIC)
Pattern II
Pattern I II
Pattern IV
Lower trapezius (% MVIC)
Pattern I II
Pattern IV
Serratus anterior (% MVIC)
Pattern I
Pattern II
Pattern I II
Pattern IV
>120
120 -90
90 -60
60 -30
30 -0
(Mean SD)
(Mean SD)
(Mean SD)
(Mean SD)
(Mean SD)
41 17)
34 15
27 13
39 14z
35 10x
28 11
34 13x
35 10z
26 9
23 10x
19 7
18 7
10 7
84
85
16 9y
21 10
15 6y
21 9
14 5y
19 8
9 5y
13 6
44
46
40
51
13
12
12y
15
38
36
32
43
8
14x
7y
14
29
26
22
33
12
10x
6y
14
14
13
13
21
8z
6z
6y
9
5 3y
73
7
6
7
13
4x
5
5y
14
consequences of such changes are related to clinical outcomes and the injury mechanism. Furthermore, such insight
may guide treatment strategies and improve clinical outcomes. Our results provide an examination method and
changes in the kinematics and muscular activities related to
scapular dyskinesis.
A visually based evaluation of scapular dyskinesis is
applicable to the assessment of alterations of scapular position and motion in clinical use.21,26,40 This study showed
that corresponding alterations of scapular kinematics could
be found in specific scapular dyskinesis patterns assessed
by our method. For example, more scapular internal rotation was found in participants with medial border of
scapular prominence, and less scapular posterior tipping
was found in those with an inferior angle of scapular
prominence. These results validate the observation/palpation method compared with a 3-D motion capture system,
especially during the arm-lowering phase.
The serratus anterior is the primary muscle that stabilizes the medial border and inferior angle of scapula to
prevent scapular winging and anterior tipping.11,29 Muscle
weakness, fatigue, and abnormal firing patterns of the serratus anterior, as well as long thoracic nerve injury, can
result in scapular winging and anterior tipping.20,25
Consistent with previous studies, our results demonstrated
decreased serratus anterior activity in participants with
medial border and inferior angle of scapula prominence. In
addition, the lower trapezius generates scapular posterior
tipping and upward rotation and operates at a constant
length to stabilize the axis of rotation of the humerus about
the glenoid during arm elevation.3,17 Inhibited activation of
the lower trapezius may cause problems with controlling
scapular motion. The present study also demonstrated a
decrease in lower trapezius activity during arm lowering in
Conclusions
Specific alterations of scapular muscular activation and
kinematics were found in different patterns of scapular
dyskinesis. The findings also validated the use of a
comprehensive classification test to assess scapular
dyskinesis. To restore normal scapular movements, it
may be necessary to inhibit the upper trapezius and
activate the lower trapezius and serratus anterior in patients with medial border and inferior angle of scapular
prominence. Because most of the changes occurred
during the arm lowering phase, assessing scapular dyskinesis in this phase is especially important.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
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